Medical and economic burden of influenza in the elderly population in central and eastern European countries

Figures & data

Table 1. Vaccination coverage rate in the elderly (aged >65 y, except Hungary in the 2008–09 and 2009–10 seasons)

Country	2006–07	2007–08	2008–09	2009–10	2010–11
Czech Republic	24%^14	32%^17	N/A	N/A	N/A
Hungary	34.1^a	34.6^a	38.4%^26 (60+ pop.)	31.8%^26 (60+ pop.)	29.5%^27
Kazakhstan	N/A	N/A	N/A	N/A	N/A
Poland	N/A	16%^17	11.4%^26	9.3%^26 and 9%^27	N/A
Romania	N/A	N/A	49.4%^26	28.5%^26	19.5%^27
Ukraine	N/A	N/A	N/A	N/A	N/A

N/A, Data not available. ^aData provided by Agnes Csohan (personal communication).

Table 2. Summary of healthcare systems in target countries

Country	Healthcare system
Czech Republic	The majority of health expenditure is covered by social health insurance.^61 Private practices in the primary setting are financed by a combination of per capita and fee-for-service payments and some patient fees. Outpatient specialists are paid via fee-for-service scheme.
Hungary	In Hungary, social health insurance covers the majority of health expenditure.^62 For primary care the financing is based on capitation, whereas specialist outpatient care is financed by a fee-for-service points system. Hungary imposes no out-of-pocket co-payment for outpatient and acute inpatient services.
Kazakhstan	Health expenditure in Kazakhstan is divided between government funding and patient out-of-pocket payments.^63 Patients pay for outpatient medications, non-essential services and commonly for inpatient medication and medical supplies. Government funding covers emergency and specific outpatient and inpatient services via a State-guaranteed benefit package.
Poland	In Poland around 70% of health expenditure is covered by public funding.^64 Although primary care is financed by per capita payments, specialist outpatient care is provided on a fee-for-service system.
Romania	Health insurance has been mandatory in Romania since 1998, and is administered and regulated by a national insurance fund.^65 Primary care practices are financed by a combination of age-weighted capitation and fee-for-services, and payments to specialists are based on a fee-for-service system. Hospitals that provide acute care are paid by a combination of case-based payments and fee-for-services. Contracts with providers and the services offered are managed by 42 district-level funds.
Ukraine	The majority of healthcare is funded by governmental redistribution of taxes.^66 Funds are distributed at local and national level, with payments to facilities dependent on their capacities and personnel rather than their services or performances. Despite government funding, out-of-pocket payments still play a significant role in total health expenditure in Ukraine.

Table 3. Summary of results from the “Diagnostic Tool” completed by country experts

Vaccination Policy	Czech Republic	Hungary	Kazakhstan	Poland	Romania	Ukraine
Are there official flu vaccine recommendations for those aged 65+?	Yes	Yes	Yes	Yes	Yes	Yes
Are World Health Organization objectives for 75% flu vaccination coverage in elderly and at risk groups adopted as national objectives?	Yes	No	No	Yes	Yes	Yes
Are there year-specific national objectives for flu vaccination coverage to achieve the 75% objective?	No	No	No	Yes	No	Yes
Is flu vaccination free (or 100% reimbursed) for patients aged 65+?	Yes	Yes	No	Yes	Yes	No
Is there a financial incentive for healthcare professionals to vaccinate their patients against flu?	Yes	No	No	No	Yes	No
Do patients receive a personal letter, voucher or invitation for a free flu vaccine and administration from the health authority?	No	Yes	No	No	No	No

Table 4. Burden of influenza in the elderly by influenza health states (2010–11 season)

Country (population aged ≥65 y, million)	Health States
	Self-managed	ILI at GP	SARI (non-ICU)	SARI (ICU)	GP care after SARI (non-ICU)	GP care after SARI (ICU)	Influenza death
	Cost per case (EUR)^1							2011 GDP per capita^4 (EUR)
Czech Republic (1.67)	4.8	32	732.5	1161.8	33.1	34.7	839.8	29 494
Hungary (1.68)	6.6	18	297.6	2883.6	19.3	19.3	944.1	20 298
Kazakhstan (1.17)	4.1	11	170.6	174.9	4.3	4.3	171.7	16 252
Poland (5.25)	5.1	27.4	512.6	8912.3	27.4	27.4	2612.5	19 458
Romania (3.25)	4.7	15.2	591.6	18 209.8	15.2	15.2	4996.1	12 148
Ukraine (6.98)	2.6	14.8	62.5	218.2	12.2	12.2	101.4	5225
	Patients aged ≥65 y per health states^2 (N)							ILI attack rate (%)
Czech Republic (1.67)	24 285	10 860	119	37	89	28	14	2.1
Hungary (1.68)	57 128	25 546	281	87	210	65	34	4.9
Kazakhstan (1.17)	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Poland (5.25)	161 215	72 092	792	244	594	183	96	4.4
Romania (3.25)	7497	3353	109	11	82	9	4	0.3
Ukraine (6.98)	44 628	19 957	219	68	164	51	27	0.9
	Annual economic burden (direct costs) of influenza in the elderly per health state calculated for the 2010–11 season (EUR)^3							Total cost (EUR)
Czech Republic (1.67)	116 861	347 536	87 347	42 721	2964	958	12 139	610 526
Hungary (1.68)	376 047	459 359	83 484	249 432	4060	1252	32 100	1 205 734
Kazakhstan (1.17)	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Poland (5.25)	822 223	1 977 045	405 791	2 175 534	16 281	5 021	250 671	5 652 565
Romania (3.25)	35 483	50 854	64 301	206 720	1236	129	22 293	381 016
Ukraine (6.98)	113 978	295 580	13 690	14 747	2000	617	2694	443 304

ILI, Influenza-like Illness; ARI, Acute Respiratory Infection; SARI, Severe Acute Respiratory Infections; GP, General Practitioner; ICU, Intensive Care Unit; N/A, Data not available. ¹Cost per influenza case per health state in elderly in Euro (in the 2010/11 season), and GDP per capita in 2011 in Euro (converted from USD with exchange rate of 30th June 2011). ²Number of 65+ patients in influenza health states (in the 2010/11 season). ³All values from 2011 in EUR. ⁴Data taken from World Bank estimates.

Figure 1. Relative healthcare burden in elderly patients per setting per country. Relative healthcare burden in Euro per setting varies considerably by country. Self-managed: influenza-like illness (ILI) and acute respiratory infection (ARI) patients that do not contact a healthcare professional; Outpatient: ILI and ARI patients that visit a healthcare professional or are referred to a GP after hospital discharge; Inpatient: Patients treated in a hospital (intensive care unit (ICU) or non-ICU) setting.

Figure 2. Influenza‐related infections and hospitalizations in target countries, week 15, Season 2011–12. Source: EuroFlu weekly bulletin²⁵. ILI, Influenza-like illness; ARI, Acute Respiratory Infection; SARI, Severe Acute Respiratory Infection; N/A, Not Available. *SARI values are estimates from EuroFlu graphs and are the count of hospitalizations in participating institutions.

Table 5. Summary of surveillance systems in target countries

Country	Surveillance system
Czech Republic	Influenza morbidity monitoring started in 1951 and age-specific incidences of ARI and total incidences of ARI-related complications have been monitored weekly in five age groups: 0–5, 6–14, 15–24, 25–59, 60+ years since 1968.^67 Since 2004, weekly incidence of ILI has been collected, with cases reported by a network of GPs and pediatricians. Weekly virological assessment of serological tests and nasopharyngeal swabs is undertaken.
Hungary	The National Center for Epidemiology coordinates the collection of influenza-related epidemiological and virological data. Between weeks 40 and 20 in each season, 1400 GPs and pediatricians — covering approximately 20% of inhabitants — report the weekly number of ILI cases. Virological surveillance, in which 170 GPs participate, involves weekly analysis of nasopharyngeal swabs from ILI patients. In the pandemic 2009–10 and in the first post-pandemic 2010–11 season, hospital surveillance was undertaken in all institutions with acute inpatient provision. Information was collected on the number of hospital and ICU admissions and deaths related to ILI. Hospital surveillance ended after the 2010–11 season.
Kazakhstan	SARI surveillance was launched in 2008, with 19 hospitals covering 7 regions.^68 Respiratory specimens are collected from all admitted SARI patients aged >1 y.
Poland	The WHO sentinel system was introduced after the 2004–05 season and before this only epidemiological surveillance was undertaken nationally. Sentinel physicians collect swabs for virological analysis and report ILI cases by age group: 0–4, 5–14, 15–64, and ≥65 y.^69 The National Influenza Centers prepare weekly reports, however, the number of sentinel sites and the population attributed to these sites is needed to calculate incidence data. In seasons 2004–05, 2005–06, and 2006–07 the numbers of sentinel-reporting physicians each week ranged from 165–219, 98–949, and 696–1054, respectively. At peak, sampling covered approximately 5.0% of the total population.
Romania	SARI surveillance was established in 12 hospitals in 2009, and a further 14 were added since 2010.^68 Between week 46 and influenza onset, samples from the first three SARI cases at each site are tested for influenza. After onset, the first SARI case of the week case is tested per site.
Ukraine	The SARI sentinel surveillance was launched in 2007, and currently 10 hospitals in four cities are participating.^68

ILI, Influenza-like Illness; ARI, Acute Respiratory Infection; SARI, Severe Acute Respiratory Infections; GP, General Practitioner; ICU, Intensive Care Unit; WHO, World Health Organization.

Figure 3. Simplified influenza treatment algorithm used to model the disease burden. Health states in the model are mutually exclusive. Transitions between states are identified with an arrow, a solid line indicates a reversible transition and unidirectional movement is shown via a dotted line. Health states are classified as Outpatient or Inpatient as shown in in the “Setting” row. Cost items are summarized below the setting. The diagnoses considered to be influenza-related per health state are listed below the diagram. ILI, Influenza-like Illness; ARI, Acute Respiratory Infection; SARI, Severe Acute Respiratory Infections; OTC, Over The Counter; GP, General Practitioner; ICU, Intensive Care Unit.

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